Variation in Trust in Cancer Information Sources by Perceptions of Social Media Health Mis- and Disinformation and by Race and Ethnicity Among Adults in the United States: Cross-Sectional Study

BACKGROUND

Mis- and disinformation on social media have become widespread, which can lead to a lack of trust in health information sources and, in turn, lead to negative health outcomes. Moreover, the effect of mis- and disinformation on trust in information sources may vary by racial and ethnic minoritized populations.

OBJECTIVE

We evaluated how trust in multiple sources of cancer information varied by perceptions of health mis- and disinformation on social media and by race and ethnicity.

METHODS

Cross-sectional, nationally representative survey data from noninstitutionalized adults in the United States from the 2022 Health Information National Trends Survey 6 (HINTS 6) were analyzed (N=4137). The dependent variable measured the level of trust in cancer information sources. The independent variables were perceptions about health mis- and disinformation on social media and race and ethnicity. Multivariable logistic regression models were adjusted for survey weight and design, age, birth gender, race and ethnicity, marital status, urban/rural designation, education, employment status, feelings about household income, frequency of social media visits, and personal and family history of cancer. We also tested the interaction effect between perceptions of social media health mis- and disinformation and participants' self-reported race and ethnicity.

RESULTS

Perception of "a lot of" health mis- and disinformation on social media, relative to perception of "less than a lot," was associated with a lower likelihood of high levels of trusting cancer information from government health agencies (odds ratio [OR] 0.60, 95% CI 0.47-0.77), family or friends (OR 0.56, 95% CI 0.44-0.71), charitable organizations (OR 0.78, 95% CI 0.63-0.96), and religious organizations and leaders (OR 0.64, 95% CI 0.52-0.79). Among White participants, those who perceived a lot of health mis- and disinformation on social media were less likely to have high trust in cancer information from government health agencies (margin=61%, 95% CI 57%-66%) and family or friends (margin=49%, 95% CI 43%-55%) compared to those who perceived less than a lot of health mis- and disinformation on social media. Among Black participants, those who perceived a lot of health mis- and disinformation on social media were less likely to have high trust in cancer information from religious organizations and leaders (margin=20%, 95% CI 10%-30%) compared to participants who perceived no or a little health mis- and disinformation on social media.

CONCLUSIONS

Certain sources of cancer information may need enhanced support against the threat of mis- and disinformation, such as government health agencies, charitable organizations, religious organizations and leaders, and family or friends. Moreover, interventions should partner with racial and ethnically minoritized populations that are more likely to have low trust in certain cancer information sources associated with mis- and disinformation on social media.

Association of food insecurity with health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic

OBJECTIVES

To examine the associations between food insecurity and health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic and examine whether the associations were less pronounced among adults with safety nets.

STUDY DESIGN

We conducted a retrospective longitudinal cohort study using the 2020-2021 Medical Expenditure Panel Survey.

METHODS

Linear probability models were used to assess the associations between food insecurity in one year and the outcomes of interest in the following year while adjusting for baseline characteristics. We performed the analyses for the entire population and then conducted stratified analyses for adults with and without Supplemental Nutrition Assistance Program (SNAP) benefits or Medicaid coverage.

RESULTS

Compared with food-secure adults, food-insecure adults were 9.1 percentage points less likely to report life satisfaction and 9.9, 10.2, and 13.2 percentage points more likely to experience delays in getting medical care, postpone or forgo medical care because of cost, and struggle with paying medical bills. Food-insecure adults were 30.4, 27.2, and 23.5 percentage points more likely to face challenges in affording necessities, paying utility bills, and meeting rent or mortgage payments on time than food-secure adults. Notably, the strengths of these associations were attenuated among adults with SNAP benefits or Medicaid coverage.

CONCLUSIONS

Food insecurity was associated with poor health, limited access to and affordability of care, and a greater financial burden of care among US adults during the pandemic. Nevertheless, safety net programs can play a critical role in alleviating adverse consequences.

Health Care Access and Utilization and the Latino Health Paradox

BACKGROUND

The Latino health paradox is the phenomenon whereby recent Latino immigrants have, on average, better health outcomes on some indicators than Latino immigrants who have lived in the United States longer and US-born Latinos and non-Latino Whites. This study examined whether the paradox holds after accounting for health care access and utilization.

METHODS

The 2019-2020 National Health Interview Survey data were used. The main predictors included population groups of foreign-born and US-born Latinos (Mexican or non-Mexican) versus US-born non-Latino Whites. Predicted probabilities of health outcomes (self-reported poor/fair health, overweight/obesity, hypertension, coronary heart disease, diabetes, cancer, and depression) were calculated and stratified by length of residence in the United States (<15 or ≥15 years) among foreign-born Latinos and sex (female or male). Multivariable analyses adjusted for having a usual source of care other than the emergency department, health insurance, a doctor visit in the past 12 months, predisposing and enabling factors, and survey year.

RESULTS

After adjusting for health care access, utilization, and predisposing and enabling factors, foreign-born Latinos, including those living in the United States ≥15 years, had lower predicted probabilities for most health outcomes than US-born non-Latino Whites, except overweight/obesity and diabetes. US-born Latinos had higher predicted probabilities of overweight/obesity and diabetes and a lower predicted probability of depression than US-born non-Latino Whites.

CONCLUSIONS

In this national survey, the Latino health paradox was observed after adjusting for health care access and utilization and predisposing and enabling factors, suggesting that, although these are important factors for good health, they do not necessarily explain the paradox.

Improving health equity through health care systems research

OBJECTIVE

To describe health equity research priorities for health care delivery systems and delineate a research and action agenda that generates evidence-based solutions to persistent racial and ethnic inequities in health outcomes.

DATA SOURCES AND STUDY SETTING

This project was conducted as a component of the Agency for Healthcare Research and Quality's (AHRQ) stakeholder engaged process to develop an Equity Agenda and Action Plan to guide priority setting to advance health equity. Recommendations were developed and refined based on expert input, evidence review, and stakeholder engagement. Participating stakeholders included experts from academia, health care organizations, industry, and government.

STUDY DESIGN

Expert group consensus, informed by stakeholder engagement and targeted evidence review.

DATA COLLECTION/EXTRACTION METHODS

Priority themes were derived iteratively through (1) brainstorming and idea reduction, (2) targeted evidence review of candidate themes, (3) determination of preliminary themes; (4) input on preliminary themes from stakeholders attending AHRQ's 2022 Health Equity Summit; and (5) and refinement of themes based on that input. The final set of research and action recommendations was determined by authors' consensus.

PRINCIPAL FINDINGS

Health care delivery systems have contributed to racial and ethnic disparities in health care. High quality research is needed to inform health care delivery systems approaches to undo systemic barriers and inequities. We identified six priority themes for research; (1) institutional leadership, culture, and workforce; (2) data-driven, culturally tailored care; (3) health equity targeted performance incentives; (4) health equity-informed approaches to health system consolidation and access; (5) whole person care; (6) and whole community investment. We also suggest cross-cutting themes regarding research workforce and research timelines.

CONCLUSIONS

As the nation's primary health services research agency, AHRQ can advance equitable delivery of health care by funding research and disseminating evidence to help transform the organization and delivery of health care.

Differences in use of high- and low-value health care between immigrant and US-born adults

OBJECTIVE

To examine differences in the use of high- and low-value health care between immigrant and US-born adults.

DATA SOURCE

The 2007-2019 Medical Expenditure Panel Survey.

STUDY DESIGN

We split the sample into younger (ages 18-64 years) and older adults (ages 65 years and over). Our outcome measures included the use of high-value care (eight services) and low-value care (seven services). Our key independent variable was immigration status. For each outcome, we ran regressions with and without individual-level characteristics.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

Before accounting for individual-level characteristics, the use of high- and low-value care was lower among immigrant adults than US-born adults. After accounting for individual-level characteristics, this difference decreased in both groups of younger and older adults. For high-value care, significant differences were observed in five services and the direction of the differences was mixed. The use of breast cancer screening was lower among immigrant than US-born younger and older adults (-5.7 [95% CI: -7.4 to -3.9] and -2.9 percentage points [95% CI: -5.6 to -0.2]) while the use of colorectal cancer screening was higher among immigrant than US-born younger and older adults (2.6 [95% CI: 0.5 to 4.8] and 3.6 [95% CI: 0.2 to 7.0] percentage points). For low-value care, we did not identify significant differences except for antibiotics for acute upper respiratory infection among younger adults and opioids for back pain among older adults (-3.5 [95% CI: -5.5 to -1.5] and -3.8[95% CI: -7.3 to -0.2] percentage points). Particularly, differences in socioeconomic status, health insurance, and care access between immigrant and US-born adults played a key role in accounting for differences in the use of high- and low-value health care. The use of high-value care among immigrant and US-born adults increased over time, but the use of low-value care did not decrease.

CONCLUSION

Differential use of high- and low-value care between immigrant and US-born adults may be partly attributable to differences in individual-level characteristics, especially socioeconomic status, health insurance, and access to care.

Social media users' perceptions about health mis- and disinformation on social media

This study used recently released nationally representative data with new measures on health information seeking to estimate the prevalence and predictors of adult social media users' perceptions of health mis- and disinformation on social media. Most adults who use social media perceive some (46%) or a lot (36%) of false or misleading health information on social media, but nearly one-fifth reported either none or a little (18%). More than two-thirds of participants reported that they were unable to assess social media information as true or false (67%). Our study identified certain population groups that might be a focus of future intervention work, such as participants who use social media to make decisions. The perception by social media users that false and misleading health information on social media is highly prevalent may lend greater urgency to mitigate the spread of false or misleading health information that harms public health.

Effects of Medicare eligibility and enrollment at age 65 among immigrants and US-born residents

BACKGROUND

Understanding the impacts of Medicare coverage among immigrants is of high policy importance, but there is currently limited evidence. In this study, we examined the effects of near universal access to Medicare coverage at age 65 years between immigrants and US-born residents.

METHODS

Using the 2007-2019 Medical Expenditure Panel Survey, we employed a regression discontinuity design, which exploits the eligibility for Medicare at age 65 years. Our outcomes were health insurance coverage, healthcare spending, access to and use of health care, and self-reported health status.

RESULTS

Medicare eligibility at age 65 led to significant increases in Medicare coverage among immigrants and US-born residents (74.6 [95% CI: 71.6-77.5] and 81.6 [95% CI: 80.5-82.7] percentage points). Medicare enrollment at age 65 decreased total healthcare spending and out-of-pocket spending by $1579 (95% CI: -2092 to 1065) and $423 (95% CI: -544 to 303) for immigrants and $1186 (95% CI: -2359 to 13) and $450 (95% CI: -774 to 127) for US-born residents. After Medicare enrollment at age 65, immigrants reported only limited improvements in overall access to and use of health care, but they reported significant increases in the use of high-value care (11.5 [95% CI: 6.8-16.2], 8.3 [95% CI: 6.0-10.6], 8.4 [95% CI: 1.0-15.8], and 2.3 [95% CI: 0.9-3.7] percentage points increase for colorectal cancer screening, eye examination for diabetes, influenza vaccine, and cholesterol measurement) and improvements in self-reported health (5.9 [95% CI: 0.9-10.8] and 4.8 [95% CI: 0.5-9.0] percentage points increase for good perceived physical and mental health). Medicare enrollment also increased prescription drug spending by $705 (95% CI: 292-1117), despite the unchanged use of prescription drugs. For US-born residents, use of high-value care, self-reported health, and prescription drug use and spending did not change substantially after Medicare enrollment.

CONCLUSION

Medicare has the potential to improve care among older adult immigrants.

Is use of a smuggler to cross the US-Mexico border associated with mental health problems among undocumented immigrants from Mexico?

Although numerous studies have found that Latine immigrants to the United States (US) have better health outcomes on average than persons born in the US, studies of persons living in Mexico have found that undocumented immigrants have worse health, especially those that were deported, compared to Mexican citizens that never migrated or migrated with authorization. However, the health outcomes of Mexican migrants using a smuggler to cross the US-Mexico border is a gap in the literature. We hypothesized that undocumented immigrant adults who used a smuggler to cross the US-Mexico border would be more likely to report mental health problems upon return to Mexico compared with undocumented immigrant adults that did not use a smuggler. We analyzed nationally representative, cross-sectional survey data of 1,563 undocumented immigrants currently living in Mexico. Most undocumented immigrants in the sample (87%) used a smuggler. Use of a smuggler by undocumented immigrant adults was associated with a 4.7% higher prevalence of emotional or psychiatric problems compared to undocumented immigrant adults that did not use a smuggler. We conclude that modality of ingress into the US is a risk factor for poorer mental health among undocumented immigrant adults.

Undocumented Latino Immigrants and the Latino Health Paradox

INTRODUCTION

Despite having worse healthcare access and other social disadvantages, immigrants have, on average, better health outcomes than U.S.-born individuals. For Latino immigrants, this is known as the Latino health paradox. It is unknown whether this phenomenon applies to undocumented immigrants.

METHODS

This study used restricted California Health Interview Survey data from 2015 to 2020. Data were analyzed to test the relationships between citizenship/documentation status and physical and mental health among Latinos and U.S.-born Whites. Analyses were stratified by sex (male/female) and length of U.S. residence (<15 years/>= 15 years).

RESULTS

Undocumented Latino immigrants had lower predicted probabilities of reporting any health condition, asthma, and serious psychological distress and had a higher probability of overweight/obesity than U.S.-born Whites. Despite having a higher probability of overweight/obesity, undocumented Latino immigrants did not have probabilities of reporting diabetes, high blood pressure, or heart disease different from those of U.S.-born Whites after adjusting for having a usual source of care. Undocumented Latina women had a lower predicted probability of reporting any health condition and a higher predicted probability of overweight/obesity than U.S.-born White women. Undocumented Latino men had a lower predicted probability of reporting serious psychological distress than U.S.-born White men. There were no differences in outcomes when comparing shorter- with longer-duration undocumented Latino immigrants.

CONCLUSIONS

This study observed that the Latino health paradox may express patterns for undocumented Latino immigrants that are different from those for other Latino immigrant groups, emphasizing the importance of accounting for documentation status when conducting research on this population.

Trends in Routine Checkup Within the Past Year Following a Hurricane

The goal of this nationally representative, cross-sectional study is to evaluate the trends in routine checkup within the last year associated with exposure to a hurricane. We compared Puerto Rico (2017 Hurricane Irma, Hurricane Maria), Texas (2017 Hurricane Harvey), and Florida (2017 Hurricane Irma, Hurricane 2018 Michael) with states that had a category 1-2 hurricane make landfall from 2014 to 2019: Georgia, Louisiana, Mississippi, North Carolina, and South Carolina. We found that states impacted by a major hurricane in 2017 had a drop in routine checkup while the states that experienced a category 1-2 landfall did have a change in that year. By the following year, all states reported an increase in routine checkup suggesting that the disruption in routine care was temporary.

Growing inequities in mental health crisis services offered to indigent patients in Puerto Rico versus the US states before and after Hurricanes Maria and Irma

OBJECTIVE

To assess changes in the availability of mental health crisis services in Puerto Rico relative to US states before and after Hurricanes Maria and Irma.

DATA SOURCES/STUDY SETTING

National Mental Health Services Surveys conducted in 2016 and 2020.

STUDY DESIGN

Repeated cross-sectional design. The independent variable was mental health facility location in Puerto Rico or a US state. Dependent variables were the availability of three mental health crisis services (psychiatric emergency walk-in services, suicide prevention services, and crisis intervention team services).

DATA COLLECTION/EXTRACTION METHODS

The proportion and per 100,000 population rate of facilities offering crisis services were calculated.

PRINCIPAL FINDINGS

The availability of crisis services at mental health facilities in Puerto Rico remained stable between 2016 and 2020. These services were offered less at indigent care facilities in Puerto Rico than US states (e.g., 38.2% vs. 49.5% for suicide prevention, p = 0.06) and the magnitude of difference increased following Hurricane Maria.

CONCLUSIONS

There are disparities between Puerto Rico and US states in the availability of mental health crisis services for indigent patients.

The impact of Medicaid funding structures on inequities in health care access for Latinos in New York, Florida, and Puerto Rico

OBJECTIVE

To study the impact of Medicaid funding structures before and after the implementation of the Affordable Care Act (ACA) on health care access for Latinos in New York (Medicaid expansion), Florida (Medicaid non-expansion), and Puerto Rico (Medicaid block grant).

DATA SOURCES

Pooled state-level data for New York, Florida, and Puerto Rico from the 2011-2019 Behavioral Risk Factor Surveillance System and data from the 2011-2019 American Community Survey and Puerto Rico Community Survey.

STUDY DESIGN

Cross-sectional study using probit with predicted margins to separately compare four health care access measures among Latinos in New York, Florida, and Puerto Rico (having health insurance coverage, having a personal doctor, delayed care due to cost, and having a routine checkup). We also used difference-in-differences to measure the probability percent change of having any health insurance and any public health insurance before (2011-2013) and after (2014-2019) the ACA implementation among citizen Latinos in low-income households.

DATA COLLECTION

The sample consisted of Latinos aged 18-64 residing in New York, Florida, and Puerto Rico from 2011 to 2019.

PRINCIPAL FINDINGS

Latinos in Florida had the lowest probability of having health care access across all four measures and all time periods compared with those in New York and Puerto Rico. While Latinos in Puerto Rico had greater overall health care access compared with Latinos in both states, health care access in Puerto Rico did not change over time. Among citizen Latinos in low-income households, New York had the greatest post-ACA probability of having any health insurance and any public health insurance, with a growing disparity with Puerto Rico (9.7% any [1.6 SE], 5.2% public [1.8 SE]).

CONCLUSIONS

Limited Medicaid eligibility (non-expansion of Florida's Medicaid program) and capped Medicaid funds (Puerto Rico's Medicaid block grant) contributed to reduced health care access over time, particularly for citizen Latinos in low-income households.

Avoiding Medicaid enrollment after the reversal of the changes in the public charge rule among Latino and Asian immigrants

OBJECTIVE

To estimate the avoidance of Medicaid enrollment among Latino and Asian immigrants due to fears about immigration status. In 2019, changes to the "public charge" rule made it difficult for immigrants to receive a green card or permanent residence visa, particularly for those who used health and nutrition benefits. Despite the Biden administration's reversal of these changes, fear and misinformation persist among immigrants.

DATA SOURCES

Pooled data from the 2017 to 2020 California Health Interview Survey.

STUDY DESIGN

We used adjusted predicted probability models to estimate differences in access to and use of health care and health insurance coverage among Latino and Asian immigrant adults with and without green cards, using US citizens as the reference. We estimated the avoidance of Medicaid enrollment among immigrants without a green card, the immigrant population subject to the public charge rule.

DATA COLLECTION/EXTRACTION METHODS

Population stratified by race/ethnicity and green card status.

PRINCIPAL FINDINGS

Latino immigrants without a green card were -23.1% (CI: -27.8, -18.4) less likely to be insured, -9.2% (CI: -12.8, -5.5) less likely to have Medicaid coverage, -9.3% (CI: -14.5, -4.1) less likely to have a usual source of care, and -8.4% (CI: -13.2, -0.3) less likely to have a physician visit relative to citizens. Asian immigrants without a green card were -11.7% (CI: -19.7, -3.72) less likely to be insured, -8.8% (CI: -11.6, -6.1) less likely to have Medicaid coverage, -11.6% (CI: -19.3, -3.9) less likely to have a usual source of care, and -11.0% (CI: -19.2, -2.3) less likely to have a physician visit. Between 107,956 and 192,905 Latino immigrants and 1294 and 4702 Asian immigrants in California likely avoided Medicaid enrollment due to fears about their immigration status.

CONCLUSION

While our estimates are lower than those of previous studies, our findings highlight barriers to health care for immigrants despite the reversal of the changes in the public charge rule. Since the public charge rule was not abolished, immigrants with low incomes might choose not to seek health care, despite recent efforts in California to expand Medicaid coverage to all eligible immigrants regardless of documentation statuses.

Changes in Coverage and Cost-Related Delays in Care for Latino Individuals After Elimination of the Affordable Care Act's Individual Mandate

This cross-sectional study examines changes in levels of health care coverage and cost-related delays in care for Latino individuals after elimination of the individual coverage mandate from the Affordable Care Act (ACA).

The Affordable Care Act and Health Care Access and Utilization Among White, Asian, and Latino Immigrants in California

OBJECTIVE

The objective of this study was to examine changes in health care access and utilization for White, Asian, and Latino immigrants associated with the implementation of the Patient Protection and Affordable Care Act (ACA) in California.

STUDY DESIGN

Using the 2011-2013 and 2015-2017 California Health Interview Survey, we examined changes in 2 health care access and 2 utilization measures among 3 immigrant racial/ethnic groups. We estimated the unadjusted and adjusted percentage point changes in the pre-ACA and post-ACA periods. Adjusted estimates were obtained using linear probability models controlling for predisposing, enabling, and need factors.

RESULTS

After the ACA was nationally implemented in 2014, rates of insurance increased for non-Latino (NL) White, NL Asian, and Latino immigrant groups in California. Latino immigrants had the largest increase in insurance coverage (14.3 percentage points), followed by NL Asian immigrants (9.9 percentage points) and NL White immigrants (9.2 percentage points). Despite benefitting from the largest increase in insurance coverage, the proportion of insured Latino immigrants was still lower than that of NL White and NL Asian immigrants. Latino immigrants reported a small but significant decrease in the usual source of care (-2.8 percentage points) and an increase in emergency department utilization (2.9 percentage points) after the ACA. No significant changes were found after the ACA in health care access and utilization among NL White and NL Asian immigrants.

CONCLUSIONS

Insurance coverage increased significantly for these 3 immigrant groups after the ACA. While Latino immigrants had the largest gain in insurance coverage, the proportion of Latino immigrants with insurance remained the lowest among the 3 immigrant racial/ethnic groups.

Health Policy Challenges Posed By Shifting Demographics And Health Trends Among Immigrants To The United States

Since the 1960s the immigrant population in the United States has increased fourfold, reaching 44.7 million, or 13.7 percent of the US population, in 2018. The shifting immigrant demography presents several challenges for US health policy makers. We examine recent trends in immigrant health and health care after the Great Recession and the nationwide implementation of the Affordable Care Act. Recent immigrants are more likely to have lower incidence of chronic health conditions than other groups in the US, although these differences vary along the citizenship and documentation status continuum. Health care inequities among immigrants and US-born residents increased after the Great Recession and later diminished after the Affordable Care Act took effect. Unremitting inequities remain, however, particularly among noncitizen immigrants. The number of aging immigrants is growing, which will present a challenge to the expansion of coverage to this population. Health care and immigration policy changes are needed to integrate immigrants successfully into the US health care system.

The Other US Border: Health Insurance Coverage Among Latino Immigrants In Puerto Rico

Puerto Rico is a US territory and a popular destination for Latino immigrants in the Caribbean. Even with few language and cultural barriers, however, many Latino immigrants in Puerto Rico are uninsured. Using data from the 2014-19 Puerto Rico Community Survey, we examined inequities in health insurance coverage for non-Puerto Rican Latinos ages 18-64 living in Puerto Rico according to citizenship status and Latino subgroup (Dominican, Cuban, Mexican, and other Latino). After controlling for potential confounders, we found that noncitizen Dominicans had a significantly lower probability of having any health insurance (57.2 percent) and having any private insurance (31.5 percent). Regardless of similarities in culture and language, Latino immigrants on the island, particularly Dominicans, experience major health insurance coverage inequities. Considering that Puerto Rico's immigration system is regulated by US federal statute, both federal and local policy makers should acknowledge and focus on reducing these immigrant disparities in health insurance coverage.

Inequities in Access to Care and Health Care Spending for Asian Americans With Cancer

BACKGROUND

Asian Americans have lower cancer screening rates than non-Latino "Whites," suggesting inequities in cancer prevention among Asian Americans. Little is known about inequities in cancer treatment between Whites and Asian Americans with cancer.

METHODS

Using the 2002-2017 Medical Expenditure Panel Survey, we examined inequities in access to care and health care spending between Whites and Asian Americans with and without cancer. Our outcomes included 3 measures of access to care and 3 measures of health care spending. We used multivariable regressions while adjusting for predisposing, enabling, and need factors and estimated the mean adjusted values of the outcomes for each group. We then examined the differences in these adjusted mean outcomes among Asian Americans relative to Whites.

RESULTS

We observed evidence of inequities that Asian Americans without cancer experienced limited access to care due to a lack of a usual source of care. The likelihood of having a usual source of care was lower among Asian Americans without cancer than Whites without cancer. Inequities were not observed among Asian Americans with cancer. Compared with Whites with cancer, Asian Americans with cancer had similar or better levels of access to care. No or marginal differences in health care spending were detected between Whites and Asian Americans with cancer. These findings were consistent in both nonelderly and elderly groups.

CONCLUSION

While Asian Americans without cancer have unmet medical needs due to limited access to care, access to care and spending are relatively equitable between Whites and Asian Americans with cancer.

Comparison of Use of Health Care Services and Spending for Unauthorized Immigrants vs Authorized Immigrants or US Citizens Using a Machine Learning Model

IMPORTANCE

Knowledge about use of health care services (health care utilization) and expenditures among unauthorized immigrant populations is uncertain because of limitations in ascertaining legal status in population data.

OBJECTIVE

To examine health care utilization and expenditures that are attributable to unauthorized and authorized immigrants vs US-born individuals.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used the data on documentation status from the Los Angeles Family and Neighborhood Survey (LAFANS) to develop a random forest classifier machine learning model. K-fold cross-validation was used to test model performance. The LAFANS is a randomized, multilevel, in-person survey of households residing in Los Angeles County, California, consisting of 2 waves. Wave 1 began in April 2000 and ended in January 2002, and wave 2 began in August 2006 and ended in December 2008. The machine learning model was then applied to a nationally representative database, the 2016-2017 Medical Expenditure Panel Survey (MEPS), to predict health care expenditures and utilization among unauthorized and authorized immigrants and US-born individuals. A generalized linear model analyzed health care expenditures. Logistic regression modeling estimated dichotomous use of emergency department (ED), inpatient, outpatient, and office-based physician visits by immigrant groups with adjusting for confounding factors. Data were analyzed from May 1, 2019, to October 14, 2020.

EXPOSURES

Self-reported immigration status (US-born, authorized, and unauthorized status).

MAIN OUTCOMES AND MEASURES

Annual health care expenditures per capita and use of ED, outpatient, inpatient, and office-based physician care.

RESULTS

Of 47 199 MEPS respondents with nonmissing data, 35 079 (74.3%) were US born, 10 816 (22.9%) were authorized immigrants, and 1304 (2.8%) were unauthorized immigrants (51.7% female; mean age, 47.6 [95% CI, 47.4-47.8] years). Compared with authorized immigrants and US-born individuals, unauthorized immigrants were more likely to be aged 18 to 44 years (80.8%), Latino (96.3%), and Spanish speaking (95.2%) and to have less than 12 years of education (53.7%). Half of unauthorized immigrants (47.1%) were uninsured compared with 15.9% of authorized immigrants and 6.0% of US-born individuals. Mean annual health care expenditures per person were $1629 (95% CI, $1330-$1928) for unauthorized immigrants, $3795 (95% CI, $3555-$4035) for authorized immigrants, and $6088 (95% CI, $5935-$6242) for US-born individuals.

CONCLUSIONS AND RELEVANCE

Contrary to much political discourse in the US, this cross-sectional study found no evidence that unauthorized immigrants are a substantial economic burden on safety net facilities such as EDs. This study illustrates the value of machine learning in the study of unauthorized immigrants using large-scale, secondary databases.

Cardiovascular disease behavioral risk factors among Latinos by citizenship and documentation status

Background

Studies have observed that recent Latino immigrants tend to have a physical health advantage compared to immigrants who have been in the US for many years or Latinos who are born in the United States. An explanation of this phenomenon is that recent immigrants have positive health behaviors that protect them from chronic disease risk. This study aims to determine if trends in positive cardiovascular disease (CVD) risk behaviors extend to Latino immigrants in California according to citizenship and documentation status.

Methods

We examined CVD behavioral risk factors by citizenship/documentation statuses among Latinos and non-Latino US-born whites in the 2011–2015 waves of the California Health Interview Survey. Adjusted multivariable logistic regressions estimated the odds for CVD behavioral risk factors, and analyses were stratified by sex.

Results

In adjusted analyses, using US-born Latinos as the reference group, undocumented Latino immigrants had the lowest odds of current smoking, binge drinking, and frequency of fast food consumption. There were no differences across the groups for fruit/vegetable intake and walking for leisure. Among those with high blood pressure, undocumented immigrants were least likely to be on medication. Undocumented immigrant women had better patterns of CVD behavioral risk factors on some measures compared with other Latino citizenship and documentation groups.

Conclusions

This study observes that the healthy Latino immigrant advantage seems to apply to undocumented female immigrants, but it does not necessarily extend to undocumented male immigrants who had similar behavioral risk profiles to US-born Latinos.

Utilization of essential preventive health services among Asians after the implementation of the preventive services provisions of the Affordable Care Act

Utilization of cost-effective essential preventive health services increased after the implementation of the Affordable Care Act's (ACA) provision that non-grandfathered private insurers provide cost-effective preventive services without cost sharing in 2010. Little is known, however, whether this change is also observed among Asians in the US. We examined patterns of preventive services utilization among Asian subgroups relative to non-Latino whites (whites) after the implementation of the ACA's preventive services provisions. Using 2013-2016 Medical Expenditure Panel Survey data, we examined utilization trends in preventive services among Asian Indians, Chinese, Filipinos, and other Asians relative to whites. We also ran logistic regression models to estimate the likelihood of having received each of the seven essential preventive services (routine checkups, flu vaccinations, cholesterol screenings, blood pressure checkups, Papanicolaou "pap" tests, mammograms, and colorectal cancer screenings). Compared to whites, Asians had higher rates of utilization of routine checkups, cholesterol screenings, and flu vaccinations, but they had lower utilization rates of blood pressure checkups, pap tests, and mammograms. The patterns of preventive services utilization differed across the Asian subgroups. All Asian subgroups, except for Filipinos, were less likely to have pap tests or mammograms than whites. Moreover, we observed a decreasing trend in having pap tests, mammograms, or colorectal cancer screenings among all Asian subgroups between 2013 and 2016. Our findings suggest that there are low cancer screening rates across Asian subgroups. This indicates the need for programs tailored to specific Asian subgroups to improve cancer screening.

Differences in Health Care Expenditures Among Non-Latino Whites and Asian Subgroups Vary Along the Distribution of the Expenditures

Using a nationally representative sample from the 2013 to 2016 Medical Expenditure Panel Survey, we examined differences among non-Latino Whites and Asian subgroups (Asian Indians, Chinese, Filipinos, and other Asians) across distributions of total health care expenditures and out-of-pocket (OOP) expenditures. For total health care expenditures, differences between Asian and White adults persisted throughout the distribution, but the magnitude of the difference was larger at no or low levels of expenditures than at high expenditure levels. A similar pattern was observed in OOP expenditures, but the magnitude of the difference was substantially larger at low levels of expenditures. The extent of the difference varied by Asian subgroup, but this trend persisted across all the subgroups. Similar trends were observed by nativity and limited English proficiency. Our findings suggest that differences in health care expenditures between Whites and Asians are more pronounced at low expenditure levels.

Access-To-Care Differences Between Mexican-Heritage And Other Latinos In California After The Affordable Care Act

We examined changes in health insurance coverage and access to and use of health care among adult (ages 18-64) Latinos in the US before (2007-13) and after (2014-16) implementation of the main provisions of the Affordable Care Act. Data from the California Health Interview Survey were used to compare respondents in the two periods. We used multivariable and decomposition regression analyses to investigate the role of documentation status in access disparities between Mexicans and other Latinos in California. Our findings show that after the implementation of these provisions in California, insurance coverage increased for US- and foreign-born Latinos, including undocumented Latinos. Our decomposition analyses show that after implementation, disparities between Mexicans and other Latinos declined with respect to having coverage and a usual source of care. Without the implementation of these provisions in 2014, these disparities would have been 5.76 percent and 0.31 percent larger, respectively. In contrast, legal documentation status was positively associated with disparities between Mexicans and other Latinos in having coverage and physician visits. If Mexican Latinos had had the same share of undocumented immigrants as other Latinos, disparities in health insurance coverage would have declined by 24.17 percent.

Racial and Ethnic Disparities in Provider-Related Barriers to Health Care for Children in California After the ACA

The aim of this study was to examine disparities in provider-related barriers to health care by race and ethnicity of children in California after the implementation of the Affordable Care Act (ACA). California Health Interview Survey child (0-11 years) survey data from 2014 to 2016 were used to conduct multivariable logistic regressions to estimate the odds of reporting any provider-related barrier, trouble finding a doctor, child’s health insurance not accepted by provider, and child not being accepted as a new patient. Compared with parents of non-Latino white children, parents of non-Latino black, Latino, Asian, and other/multiracial children were not more likely to report experiencing any of the 4 provider-related barrier measures. The associations between children’s race and ethnicity and parents’ reports of provider-related barriers were nonsignificant. Findings demonstrate that there are no significant racial/ethnic differences in provider-related barriers to health care for children in California in the post-ACA era.

Examining EMTALA in the era of the patient protection and Affordable Care Act

Background

Little is known regarding the characteristics of hospitals that violate the Emergency Medical Treatment and Labor Act (EMTALA). This study addresses this gap by examining EMTALA settlements from violating hospitals and places these descriptive results within the current debate surrounding the Patient Protection and Affordable Care Act (ACA).

Methods

We conducted a content analysis of all EMTALA Violations that resulted in civil monetary penalty settlements from 2002–2015 and created a dataset describing the nature of each settlement. These data were then matched with Thomson Healthcare hospital data. We then present descriptive statistics of each settlement over time, plot settlements by type of violation, and provide the geographic distribution of settlements.

Results

Settlements resulting from EMTALA violations decreased from a high of 46 in 2002 to a low of 6 in 2015, a decline of 87%. Settlements resulting from violations most commonly occurred for failure to screen and failure to stabilize patients in need of emergency care. Settlements were most common in hospitals in the South (48%) and in urban areas (74%). Among Disproportionate Share Hospitals (DSH) with a violation, the majority (62%) were located in the South or in urban areas (65%). Violating hospitals incurred annual settlements of $31,734 on average, for a total $5,299,500 over the study period.

Conclusions

EMTALA settlements declined prior to and after the implementation of the ACA and were most common in the South and in urban areas. EMTALA's status as an unfunded mandate, scheduled cuts to DSH payments and efforts to repeal the ACA threaten the financial viability of safety-net hospitals and could result in an increase of EMTALA violations. Policymakers should be cognizant of the interplay between the ACA and complementary laws, such as EMTALA, when considering changes to the law.

Multilevel Interventions To Address Health Disparities Show Promise In Improving Population Health

Multilevel interventions are those that affect at least two levels of influence-for example, the patient and the health care provider. They can be experimental designs or natural experiments caused by changes in policy, such as the implementation of the Affordable Care Act or local policies. Measuring the effects of multilevel interventions is challenging, because they allow for interaction among levels, and the impact of each intervention must be assessed and translated into practice. We discuss how two projects from the National Institutes of Health's Centers for Population Health and Health Disparities used multilevel interventions to reduce health disparities. The interventions, which focused on the uptake of the human papillomavirus vaccine and community-level dietary change, had mixed results. The design and implementation of multilevel interventions are facilitated by input from the community, and more advanced methods and measures are needed to evaluate the impact of the various levels and components of such interventions.

The Affordable Care Act Attenuates Financial Strain According to Poverty Level

We use data from the 2011-2016 National Health Interview Survey to examine how the Patient Protection and Affordable Care Act (ACA) has influenced disparities in health care-related financial strain, access to care, and utilization of services by categories of the Federal Poverty Level (FPL). We use multivariable regression analyses to determine the ACA's effects on these outcome measures, as well as to determine how changes in these measures varied across different FPL levels. We find that the national implementation of the ACA's insurance expansion provisions in 2014 was associated with improvements in health care-related financial strain, access, and utilization. Relative to adults earning more than 400% of the FPL, the largest effects were observed among those earning between 0% to 124% and 125% to 199% of the FPL after the implementation of the ACA. Both groups experienced reductions in disparities in financial strain and uninsurance relative to the highest FPL group. Overall, the ACA has attenuated health care-related financial strain and improved access to and the utilization of health services for low- and middle-income adults who have traditionally not met income eligibility requirements for public insurance programs. Policy changes that would replace the ACA with less generous age-based tax subsidies and reductions in Medicaid funding could reverse these gains.

Community Residents' Beliefs About Neighborhood Corner Stores in 2 Latino Communities: Implications for Interventions to Improve the Food Environment

We assessed community residents' perceptions of corner stores to better understand what facilitates and deters patronage at these food outlets. Data came from 978 household interviews in 2 Latino communities undergoing corner store interventions. Chi-square tests, an independent sample t test, and a multivariate logistic regression were conducted to assess the relationship between residents' perceptions about corner stores and their reported patronage at these food outlets. Residents reported that corner stores do not sell a variety of fruits and vegetables and are not places where one can get information about healthy eating. Convenience, cleanliness, positive customer service, availability of culturally appropriate items, and availability of quality fresh fruit increased the odds of store patronage. Simply providing healthy foods will not incentivize patrons to purchase them. Corner store interventions can be more effective if they address the characteristics that community residents prioritize.

Comparing Lay Community and Academic Survey Center Interviewers in Conducting Household Interviews in Latino Communities

BACKGROUND

The employment of professional interviewers from academic survey centers to conduct surveys has been standard practice. Because one goal of community-engaged research is to provide professional skills to community residents, this paper considers whether employing locally trained lay interviewers from within the community may be as effective as employing interviewers from an academic survey center with regard to unit and item nonresponse rates and cost.

METHODS

To study a nutrition-focused intervention, 1035 in-person household interviews were conducted in East Los Angeles and Boyle Heights, 503 of which were completed by lay community interviewers. A chi-square test was used to assess differences in unit nonresponse rates between professional and community interviewers and Welch's t tests were used to assess differences in item nonresponse rates. A cost comparison analysis between the two interviewer groups was also conducted.

RESULTS

Interviewers from the academic survey center had lower unit nonresponse rates than the lay community interviewers (16.2% vs. 23.3%; p < 0.01). However, the item nonresponse rates were lower for the community interviewers than the professional interviewers (1.4% vs. 3.3%; p < 0.01). Community interviewers cost approximately $415.38 per survey whereas professional interviewers cost approximately $537.29 per survey.

CONCLUSIONS

With a lower cost per completed survey and lower item nonresponse rates, lay community interviewers are a viable alternative to professional interviewers for fieldwork in community-based research. Additional research is needed to assess other important aspects of data quality interviewer such as interviewer effects and response error.

Training the Next Generation of Latino Health Researchers: A Multilevel, Transdisciplinary, Community-Engaged Approach

Reducing health disparities is a national public health priority. Latinos represent the largest racial/ethnic minority group in the United States and suffer disproportionately from poor health outcomes, including cardiovascular disease risk. Academic training programs are an opportunity for reducing health disparities, in part by increasing the diversity of the public health workforce and by incorporating training designed to develop a skill set to address health disparities. This article describes the Training and Career Development Program at the UCLA Center for Population Health and Health Disparities: a multilevel, transdisciplinary training program that uses a community-engaged approach to reduce cardiovascular disease risk in two urban Mexican American communities. Results suggest that this program is effective in enhancing the skill sets of traditionally underrepresented students to become health disparities researchers and practitioners.

Integrated Interventions for Improving Total Worker Health: A Panel Report From the National Institutes of Health Pathways to Prevention Workshop: Total Worker Health-What's Work Got to Do With It?

This National Institutes of Health (NIH) Pathways to Prevention workshop was cosponsored by the NIH Office of Disease Prevention; National Heart, Lung, and Blood Institute; and National Institute for Occupational Safety and Health of the Centers for Disease Control and Prevention. A multidisciplinary working group developed the agenda, and an evidence-based practice center prepared an evidence report through a contract with the Agency for Healthcare Research and Quality. During the 1.5-day workshop, experts discussed the body of evidence and participants commented during open discussions. After weighing the data from the evidence report, expert presentations, and public comments, an unbiased, independent panel prepared a draft report that identified research gaps and future research priorities. The report was posted on the NIH Office of Disease Prevention Web site for 5 weeks for public comment. This article highlights 8 recommendations critical for advancing the science of integrated interventions to improve the total health of workers.

The association between self-rated eating habits and dietary behavior in two Latino neighborhoods: Findings from Proyecto MercadoFRESCO

OBJECTIVE

Latinos are the largest racial and ethnic minority group in the United States and bear a disproportionate burden of obesity related chronic disease. Despite national efforts to improve dietary habits and prevent obesity among Latinos, obesity rates remain high. The objective of this study is to explore the relationship between self-rated dietary quality and dietary behavior among Latinos and how this may vary by socio-demographics to help inform future public health efforts aiming to improve eating habits and obesity rates.

DESIGN

Cross-sectional study using a series of chi-square tests, the non-parametric Wilcoxon-Mann-Whitney test and logistic regression to explore self-rated eating habits.

SETTING

Two urban, low-income, predominantly Latino neighborhoods in Los Angeles County.

SUBJECTS

1000 adults who self-identified as their household's primary food purchaser and preparer were interviewed from 2012 to 2013. Households were randomly selected based on their proximity to corner stores participating in a project to improve the food environment.

RESULTS

Most respondents (59%) report "good" eating habits. Significant associations between "good" eating habits and overall health, fruit and vegetable consumption were observed (p < 0.001). Despite these promising findings, we also find high levels of regular soda and energy-dense food consumption.

CONCLUSION

This study revealed a general understanding that healthy dietary habits are associated with fruit and vegetable consumption among Latinos in two urban neighborhoods. However, there is a need for more targeted health promotion and nutrition education efforts on the risks associated with soda and energy-dense food consumption to help improve dietary habits and obesity levels in low-income Latino communities.

Understanding health-care access and utilization disparities among Latino children in the United States

It is important to understand the source of health-care disparities between Latinos and other children in the United States. We examine parent-reported health-care access and utilization among Latino, White, and Black children (≤17 years old) in the United States in the 2006-2011 National Health Interview Survey. Using Blinder-Oaxaca decomposition, we portion health-care disparities into two parts (1) those attributable to differences in the levels of sociodemographic characteristics (e.g., income) and (2) those attributable to differences in group-specific regression coefficients that measure the health-care 'return' Latino, White, and Black children receive on these characteristics. In the United States, Latino children are less likely than Whites to have a usual source of care, receive at least one preventive care visit, and visit a doctor, and are more likely to have delayed care. The return on sociodemographic characteristics explains 20-30% of the disparity between Latino and White children in the usual source of care, delayed care, and doctor visits and 40-50% of the disparity between Latinos and Blacks in emergency department use and preventive care. Much of the health-care disadvantage experienced by Latino children would persist if Latinos had the sociodemographic characteristics as Whites and Blacks.

E-cigarette use and disparities by race, citizenship status and language among adolescents

INTRODUCTION

E-cigarette use among adolescents is on the rise in the U.S. However, limited attention has been given to examining the role of race, citizenship status and language spoken at home in shaping e-cigarette use behavior.

METHODS

Data are from the 2014 Adolescent California Health Interview Survey, which interviewed 1052 adolescents ages 12-17. Lifetime e-cigarette use was examined by sociodemographic characteristics. Separate logistic regression models predicted odds of ever-smoking e-cigarettes from race, citizenship status and language spoken at home. Sociodemographic characteristics were then added to these models as control variables and a model with all three predictors and controls was run. Similar models were run with conventional smoking as an outcome.

RESULTS

10.3% of adolescents ever used e-cigarettes. E-cigarette use was higher among ever-smokers of conventional cigarettes, individuals above 200% of the Federal Poverty Level, US citizens and those who spoke English-only at home. Multivariate analyses demonstrated that citizenship status and language spoken at home were associated with lifetime e-cigarette use, after accounting for control variables. Only citizenship status was associated with e-cigarette use, when controls variables race and language spoken at home were all in the same model.

CONCLUSIONS

Ever use of e-cigarettes in this study was higher than previously reported national estimates. Action is needed to curb the use of e-cigarettes among adolescents. Differences in lifetime e-cigarette use by citizenship status and language spoken at home suggest that less acculturated individuals use e-cigarettes at lower rates.

Substantial improvements not seen in health behaviors following corner store conversions in two Latino food swamps

Background

The effectiveness of food retail interventions is largely undetermined, yet substantial investments have been made to improve access to healthy foods in food deserts and swamps via grocery and corner store interventions. This study evaluated the effects of corner store conversions in East Los Angeles and Boyle Heights, California on perceived accessibility of healthy foods, perceptions of corner stores, store patronage, food purchasing, and eating behaviors.

Methods

Household data (n = 1686) were collected at baseline and 12- to 24-months post-intervention among residents surrounding eight stores, three of which implemented a multi-faceted intervention and five of which were comparisons. Bivariate analyses and logistic and linear regressions were employed to assess differences in time, treatment, and the interaction between time and treatment to determine the effectiveness of this intervention.

Results

Improvements were found in perceived healthy food accessibility and perceptions of corner stores. No changes were found, however, in store patronage, purchasing, or consumption of fruits and vegetables.

Conclusions

Results suggest limited effectiveness of food retail interventions on improving health behaviors. Future research should focus on other strategies to reduce community-level obesity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3074-1) contains supplementary material, which is available to authorized users.

Racial and Ethnic Disparities in Health Care Access and Utilization Under the Affordable Care Act

OBJECTIVE

To examine racial and ethnic disparities in health care access and utilization after the Affordable Care Act (ACA) health insurance mandate was fully implemented in 2014.

RESEARCH DESIGN

Using the 2011-2014 National Health Interview Survey, we examine changes in health care access and utilization for the nonelderly US adult population. Multivariate linear probability models are estimated to adjust for demographic and sociodemographic factors.

RESULTS

The implementation of the ACA (year indicator 2014) is associated with significant reductions in the probabilities of being uninsured (coef=-0.03, P<0.001), delaying any necessary care (coef=-0.03, P<0.001), forgoing any necessary care (coef=-0.02, P<0.001), and a significant increase in the probability of having any physician visits (coef=0.02, P<0.001), compared with the reference year 2011. Interaction terms between the 2014 year indicator and race/ethnicity demonstrate that uninsured rates decreased more substantially among non-Latino African Americans (African Americans) (coef=-0.04, P<0.001) and Latinos (coef=-0.03, P<0.001) compared with non-Latino whites (whites). Latinos were less likely than whites to delay (coef=-0.02, P<0.001) or forgo (coef=-0.02, P<0.001) any necessary care and were more likely to have physician visits (coef=0.03, P<0.005) in 2014. The association between year indicator of 2014 and the probability of having any emergency department visits is not significant.

CONCLUSIONS

Health care access and insurance coverage are major factors that contributed to racial and ethnic disparities before the ACA implementation. Our results demonstrate that racial and ethnic disparities in access have been reduced significantly during the initial years of the ACA implementation that expanded access and mandated that individuals obtain health insurance.

Access to and Use of Health Care Services Among Latinos in East Los Angeles and Boyle Heights

This study examined differences in access, utilization, and barriers to health care by nativity, language spoken at home, and insurance status in East Los Angeles and Boyle Heights, California. Data from household interviews of neighborhood residents conducted as part of a corner store intervention project were used. Binary and multinomial logistic regression models were fitted. Results showed that uninsured and foreign-born individuals were differentially affected by lack of access to and utilization of health care. While the Affordable Care Act may ameliorate some disparities, the impact will be limited because of the exclusion of key groups, like the undocumented, from benefits.

Proyecto MercadoFRESCO: a multi-level, community-engaged corner store intervention in East Los Angeles and Boyle Heights

Urban food swamps are typically situated in low-income, minority communities and contribute to overweight and obesity. Changing the food landscape in low income and underserved communities is one strategy to combat the negative health consequences associated with the lack of access to healthy food resources and an abundance of unhealthy food venues. In this paper, we describe Proyecto MercadoFRESCO (Fresh Market Project), a corner store intervention project in East Los Angeles and Boyle Heights in California that used a multi-level approach with a broad range of community, business, and academic partners. These are two neighboring, predominantly Latino communities that have high rates of overweight and obesity. Located in these two communities are approximately 150 corner stores. The project used a community-engaged approach to select, recruit, and convert four corner stores, so that they could become healthy community assets in order to improve residents' access to and awareness of fresh and affordable fruits and vegetables in their immediate neighborhoods. We describe the study framework for the multi-level intervention, which includes having multiple stakeholders, expertise in corner store operations, community and youth engagement strategies, and social marketing campaigns. We also describe the evaluation and survey methodology to determine community and patron impact of the intervention. This paper provides a framework useful to a variety of public health stakeholders for implementing a community-engaged corner store conversion, particularly in an urban food swamp.

Access to Care and Cardiovascular Disease Prevention: A Cross-Sectional Study in 2 Latino Communities

Cardiovascular disease (CVD) is the leading killer of Americans. CVD is understudied among Latinos, who have high levels of CVD risk factors. This study aimed to determine whether access to health care (ie, insurance status and having a usual source of care) is associated with 4 CVD prevention factors (ie, health care utilization, CVD screening, information received from health care providers, and lifestyle factors) among Latino adults and to evaluate whether the associations depended on CVD clinical risk/disease.Data were collected as part of a community-engaged food environment intervention study in East Los Angeles and Boyle Heights, CA. Logistic regressions were fitted with insurance status and usual source of care as predictors of the 4 CVD prevention factors while controlling for demographics. Analyses were repeated with interactions between self-reported CVD clinical risk/disease and access to care measures.Access to health care significantly increased the odds of CVD prevention. Having a usual source of care was associated with all factors of prevention, whereas being insured was only associated with some factors of prevention. CVD clinical risk/disease did not moderate any associations.Although efforts to reduce CVD risk among Latinos through the Affordable Care Act could be impactful, they might have limited impact in curbing CVD among Latinos, via the law's expansion of insurance coverage. CVD prevention efforts must expand beyond the provision of insurance to effectively lower CVD rates.

Transdisciplinary cardiovascular and cancer health disparities training: experiences of the centers for population health and health disparities

The Centers for Population Health and Health Disparities program promotes multilevel and multifactorial health equity research and the building of research teams that are transdisciplinary. We summarized 5 areas of scientific training for empowering the next generation of health disparities investigators with research methods and skills that are needed to solve disparities and inequalities in cancer and cardiovascular disease. These areas include social epidemiology, multilevel modeling, health care systems or health care delivery, community-based participatory research, and implementation science. We reviewed the acquisition of the skill sets described in the training components; these skill sets will position trainees to become leaders capable of effecting significant change because they provide tools that can be used to address the complexities of issues that promote health disparities.

Latino Population Growth and Hospital Uncompensated Care in California

OBJECTIVES

We examined the association between the size and growth of Latino populations and hospitals' uncompensated care in California.

METHODS

Our sample consisted of general acute care hospitals in California operating during 2000 and 2010 (n = 251). We merged California hospital data with US Census data for each hospital service area. We used spatial analysis, multivariate regression, and fixed-effect models.

RESULTS

We found a significant association between the growth of California's Latino population and hospitals' uncompensated care in the unadjusted regression. This association was still significant after we controlled for hospital and community population characteristics. After we added market characteristics into the final model, this relationship became nonsignificant.

CONCLUSIONS

Our findings suggest that systematic support is needed in areas with rapid Latino population growth to control hospitals' uncompensated care, especially if Latinos are excluded from or do not respond to the insurance options made available through the Affordable Care Act. Improving availability of resources for hospitals and providers in areas with high Latino population growth could help alleviate financial pressures.

Policy dilemmas in Latino health care and implementation of the Affordable Care Act

The changing Latino demographic in the United States presents a number of challenges to health care policy makers, clinicians, organizations, and other stakeholders. Studies have demonstrated that Latinos tend to have worse patterns of access to, and utilization of, health care than other ethnic and racial groups. The implementation of the Affordable Care Act (ACA) of 2010 may ameliorate some of these disparities. However, even with the ACA, it is expected that Latinos will continue to have problems accessing and using high-quality health care, especially in states that are not expanding Medicaid eligibility as provided by the ACA. We identify four current policy dilemmas relevant to Latinos' health and ACA implementation: (a) the need to extend coverage to the undocumented; (b) the growth of Latino populations in states with limited insurance expansion;

The association between nutrition facts label utilization and comprehension among Latinos in two east Los Angeles neighborhoods

BACKGROUND

The Nutrition Facts label can facilitate healthy dietary practices. There is a dearth of research on Latinos' utilization and comprehension of the Nutrition Facts label.

OBJECTIVE

To measure use and comprehension of the Nutrition Facts label and to identify correlates among Latinos in East Los Angeles, CA.

DESIGN

Cross-sectional interviewer-administered survey using computer-assisted personal interview software, conducted in either English or Spanish in the participant's home.

PARTICIPANTS/SETTING

Eligibility criteria were: living in a household within the block clusters identified, being age 18 years or older, speaking English or Spanish, identifying as Latino and as the household's main food purchaser and preparer. Analyses were based on 269 eligible respondents.

STATISTICAL ANALYSES PERFORMED

χ(2) test and multivariate logistic regression analysis assessed the associations among the main outcomes and demographics. Multiple imputations addressed missing data.

RESULTS

Sixty percent reported using the label; only 13% showed adequate comprehension of the label. Utilization was associated with being female, speaking Spanish, and being below the poverty line. Comprehension was associated with younger age, not being married, and higher education. Utilization was not associated with comprehension.

CONCLUSIONS

Latinos who are using the Nutrition Facts label are not correctly interpreting the available information. Targeted education is needed to improve use and comprehension of the Nutrition Facts label to directly improve diet, particularly among males, older Latinos, and those with less than a high school education.